Pharmacology Practice Test #9: Endocrine and Insulin

Answer: C. "I'll take it on an empty stomach with a glass of water at the same time each morning, and I'll keep my iron and calcium pills several hours away from it."

Rationale: Levothyroxine absorption is reduced by food and by products such as calcium, iron and antacids. The product labeling advises taking it on an empty stomach with water, usually 30 to 60 minutes before breakfast, at the same time every day, and separating it from calcium and iron supplements by several hours (the labeling gives at least 4 hours). Consistent timing keeps blood levels steady so the prescriber can adjust the dose by TSH results. Option A is wrong because taking it with food and calcium lowers absorption. Option B is wrong because hypothyroidism usually needs lifelong replacement; feeling better means the dose is working, not that the drug is no longer needed. Option D is wrong because a racing heart, heat intolerance, tremor, insomnia or chest pain are signs of too much thyroid hormone and should be reported to the provider.

Answer: A. Tell the client to hold the next PTU dose and arrange to be seen by the provider today for liver function tests

Rationale: PTU carries a boxed warning for severe liver injury and acute liver failure, which can be fatal. Dark urine, jaundice (yellow sclera or skin), nausea, loss of appetite, fatigue or right upper abdominal pain are possible signs of liver injury. The client should hold the drug and be evaluated promptly; the provider decides on liver function testing and whether to stop PTU. Because of this risk, PTU is generally reserved for specific situations such as the first trimester of pregnancy, thyroid storm, or clients who cannot take methimazole. Antithyroid drugs can also cause agranulocytosis, so sore throat and fever must be reported too. Option B is wrong because jaundice and dark urine are not simple stomach upset. Option C is wrong because waiting a week delays care for possible liver failure. Option D is wrong because continuing the drug could worsen the liver injury.

Answer: D. "After I give the glucagon, I'll turn him onto his side, and once he is awake and can swallow, I'll give him some sugar and then a snack."

Rationale: Glucagon is used when a person with hypoglycemia cannot safely eat or drink, such as when unconscious, having a seizure, or unable to swallow. Nausea and vomiting are common after glucagon, so the person is turned onto the side to protect the airway. Once awake and able to swallow, the person takes a fast-acting carbohydrate followed by a longer-acting snack or meal, because the effect of glucagon is short and the glucose can drop again. Family members should follow the instructions for their specific product (injection, autoinjector or nasal powder) and call emergency services as directed, especially if the person does not respond. Option A is wrong because nothing is given by mouth to a person who is unconscious; it can be aspirated. Option B is wrong because lying flat increases the risk of aspiration if vomiting occurs. Option C is wrong because an unresponsive person needs emergency help without delay.

Answer: B. "Metoprolol can hide the shakiness and fast heartbeat of low blood sugar, so check your glucose if you feel sweaty, hungry, confused or unusually tired."

Rationale: Many warning signs of hypoglycemia (tremor, palpitations, fast heart rate, anxiety) come from the sympathetic nervous system. Beta blockers such as metoprolol blunt these signs, so a client may not notice low blood sugar until it is severe. Sweating is usually preserved, and hunger, confusion, unusual fatigue or behavior changes can still be clues, so the client should check a glucose level when these occur and monitor as the provider recommends. Sulfonylureas such as glipizide stimulate insulin release and can cause hypoglycemia, especially with skipped meals, older age or reduced kidney function. Option A is wrong because beta blockers slow the heart and hide, not exaggerate, these signs. Option C is wrong because the two drugs can be used together with monitoring; the client should not stop a prescribed drug without the provider. Option D is wrong because the client still needs a fast-acting carbohydrate available at all times.

Answer: C. Notify the provider of possible ketoacidosis and anticipate testing for ketones and blood gases, holding empagliflozin as prescribed

Rationale: SGLT2 inhibitors such as empagliflozin, dapagliflozin and canagliflozin can cause ketoacidosis even when the blood glucose is only mildly raised (euglycemic DKA). Risk rises with vomiting, poor intake, acute illness, surgery and alcohol use. Nausea, vomiting, abdominal pain, fatigue and deep, rapid (Kussmaul) breathing are warning signs. The nurse notifies the provider and anticipates blood or urine ketones, blood gases and an anion gap; the drug is held as prescribed. The labeling also advises stopping these drugs for a set number of days before scheduled surgery, per the specific product and the prescriber. Option A is wrong because a near-normal glucose does not rule out ketoacidosis with this drug class. Option B is wrong because these symptoms are not expected and need evaluation. Option D is wrong because continuing the drug may worsen the ketoacidosis.

Answer: D. Severe, constant pain in the upper abdomen that spreads to the back, with vomiting

Rationale: GLP-1 receptor agonists such as semaglutide, liraglutide and dulaglutide have been linked to acute pancreatitis. Severe, persistent abdominal pain that may spread to the back, with or without vomiting, needs prompt evaluation; the drug is stopped while pancreatitis is suspected, per the labeling and the provider. These drugs are also associated with gallbladder disease, and they carry a boxed warning about thyroid C-cell tumors, so they are not used in clients with a personal or family history of medullary thyroid carcinoma or MEN 2. Options A, B and C are expected effects: GLP-1 agonists slow stomach emptying and reduce appetite, so early fullness, mild nausea that eases over time and weight loss are common and are not emergencies.

Answer: A. Give the glargine in its own syringe, separate from the lispro

Rationale: Insulin glargine is a long-acting basal insulin with an acidic pH. Mixing it with another insulin changes how it is absorbed and how long it lasts, so the labeling says it must not be mixed or diluted; it is given as its own subcutaneous injection. Option B is wrong because the "clear before cloudy" mixing technique applies to regular insulin with NPH, not to glargine. Option C is wrong because glargine is a clear solution; NPH is the cloudy suspension that is rolled before use. Option D is wrong because glargine is for subcutaneous use only; regular insulin is the type commonly used for IV infusions, per facility protocol and prescriber order.

Answer: B. "I keep my backup pens in the freezer so they last longer."

Rationale: Insulin must never be frozen. Freezing damages the insulin, and insulin that has been frozen should not be used even after it thaws. Unopened insulin is generally stored in the refrigerator until the expiration date. Once a pen or vial is in use, it can usually be kept at room temperature for a limited number of days; that number differs by product, so the client follows the instructions for the specific insulin and discards it after that time even if some is left. Extreme heat and direct sunlight also reduce potency. Options A, C and D are all correct statements and do not need further teaching.

Answer: D. "Give yourself the emergency hydrocortisone injection as you were taught, then get emergency care now."

Rationale: A client with adrenal insufficiency cannot make enough cortisol to respond to illness. Fever and vomiting raise the need for cortisol while preventing the oral dose from being absorbed, which can quickly lead to adrenal crisis (low blood pressure, shock, low sodium, high potassium, low glucose). Sick-day plans, set by the endocrinologist, usually increase the glucocorticoid dose during fever or illness; when the client cannot keep oral medication down, the plan is to give injectable hydrocortisone and seek emergency care. Option A is wrong because skipping doses during illness can trigger adrenal crisis. Option B is wrong because fludrocortisone is a mineralocorticoid that helps hold salt and water; it does not replace cortisol, and the client cannot keep oral medication down anyway. Option C is wrong because waiting days is unsafe for a client who is vomiting.

Answer: A. Headache, new confusion and a 2 kg weight gain since starting the drug, with serum sodium down from 140 to 128 mEq/L

Rationale: Desmopressin is a synthetic form of antidiuretic hormone that makes the kidneys hold water. If the client keeps drinking large amounts or the dose is too high, water builds up and dilutes the blood sodium (hyponatremia). Headache, nausea, confusion, weight gain and a falling sodium are warning signs, and severe hyponatremia can cause seizures. A sodium of 128 mEq/L is below the usual reference range and, with new neurologic symptoms, needs prompt reporting. The nurse monitors weight, intake and output and serum sodium, and teaches the client to drink only as directed by the prescriber. Options B, C and D show the drug is working as intended: less urine, more concentrated urine, less thirst and less nighttime urination.